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Otolaryngology--head and Neck Surgery :... Apr 2023Enhanced recovery after surgery (ERAS) protocols aim to optimize the pre-, intra-, and postoperative care of patients to improve surgery outcomes, reduce complications,... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Enhanced recovery after surgery (ERAS) protocols aim to optimize the pre-, intra-, and postoperative care of patients to improve surgery outcomes, reduce complications, decrease length of stay, and more. We aim to perform a systematic review and meta-analysis of ERAS protocols for head and neck cancer surgery with or without microvascular reconstruction.
DATA SOURCES
PubMed, Embase, and Web of Science databases were queried, and abstracts were screened independently by 2 investigators.
REVIEW METHODS
This review was conducted in accordance with the PRISMA guidelines. We included comparative observational studies but excluded animal studies, case reports, and case series.
RESULTS
Of 557 articles initially reviewed by title and/or abstract, we identified 30 for full-text screening, and 9 met the criteria for qualitative synthesis. Meta-analysis of length of stay revealed a mean decrease of 1.37 days (95% CI, 0.77-1.96; I = 0%; P < .00001) with the ERAS group as compared with non-ERAS controls. The standardized mean difference of the morphine milligram equivalent was 0.72 lower (95% CI, 0.26-1.18; I = 82%; P = .002) in the ERAS group vs controls. The quality of studies was moderate with a median MINORS score of 18.5 (range, 13.5-21.5).
CONCLUSION
Implementation of ERAS protocols can lead to decreases in length of stay and opioid drug utilization. However, further high-quality prospective studies of ERAS protocols are needed, especially with stratified analysis of outcomes based on the type of head and neck cancer surgery.
Topics: Humans; Enhanced Recovery After Surgery; Head and Neck Neoplasms; Length of Stay; Postoperative Care; Postoperative Complications; Prospective Studies; Clinical Protocols
PubMed: 35290105
DOI: 10.1177/01945998221082541 -
American Journal of Obstetrics &... May 2021This study aimed to determine the efficacy of perioperative (pre- or intraoperative) intravenous acetaminophen in improving postcesarean pain control in healthy women... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
This study aimed to determine the efficacy of perioperative (pre- or intraoperative) intravenous acetaminophen in improving postcesarean pain control in healthy women receiving regional anesthesia.
DATA SOURCES
MEDLINE, Ovid, ClinicalTrials.gov, and Scopus were searched from their inception to September 2019.
STUDY ELIGIBILITY CRITERIA
A systematic review of the literature was performed to identify all randomized placebo-controlled trials examining the effect of perioperative intravenous acetaminophen on postcesarean pain control and other postoperative outcomes. Included trials examined women who were healthy and received regional anesthesia before cesarean delivery at term.
STUDY APPRAISAL AND SYNTHESIS METHODS
The primary outcome was 24-hour postoperative pain scores with movement as measured by the individual studies. Secondary outcomes included intravenous morphine milligram equivalents used postoperatively. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of mean difference with 95% confidence interval.
RESULTS
Notably, 4 randomized placebo-controlled trials were identified that met the inclusion criteria with a total of 190 in the intervention arm vs 174 women in the control group. Patients in the intervention group received 1000 mg intravenous acetaminophen in 3 of the studies and 2000 mg intravenous acetaminophen in 1 study. All patients received regional anesthesia before surgery. The medication was given anywhere from 1 hour before surgery to intraoperatively immediately after delivery of the fetus. Pain scores 24 hours after surgery were only available in 1 study. The use of opioids as measured by morphine milligram equivalents after surgery was similar for patients receiving perioperative intravenous acetaminophen and those receiving placebo (38.7 vs 42.55; mean difference, -2.54; 95% confidence interval, -9.24 to 4.16). Only 1 study showed decreased postoperative pain scores when using perioperative intravenous acetaminophen, and this was limited to the first 4 hours after surgery. Importantly, these patients did not receive long-acting neuraxial opioids, which may account for the finding of improved pain control in the early postoperative period.
CONCLUSION
There are limited data available on the use of perioperative intravenous acetaminophen for cesarean delivery performed at term with regional anesthesia. The use of long-acting neuraxial opioids may make perioperative (pre- or intracesarean) intravenous acetaminophen unnecessary, whereas intravenous (or oral) acetaminophen may become more effective as neuraxial opioid analgesia wears off. More level-1 data are needed.
Topics: Acetaminophen; Administration, Intravenous; Analgesics, Opioid; Female; Humans; Pain, Postoperative; Pregnancy; Randomized Controlled Trials as Topic
PubMed: 33618034
DOI: 10.1016/j.ajogmf.2021.100338 -
Neurosurgery Jul 2023Scalp block is regional anesthetic injection along nerves innervating the cranium. Scalp blocks for craniotomy may decrease postoperative pain and opioid consumption.... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Scalp block is regional anesthetic injection along nerves innervating the cranium. Scalp blocks for craniotomy may decrease postoperative pain and opioid consumption. Benefits may extend beyond the anesthetic period.
OBJECTIVE
To analyze evidence for scalp block on postoperative pain and opioid use.
METHODS
This systematic review and meta-analysis, Prospective Register of Systematic Reviews registration (CRD42022308048), included Ovid Medical Literature Analysis and Retrieval System Online, Embase, and Cochrane Central Register of Controlled Trials inception through February 9, 2022. Only randomized controlled trials were included. We excluded studies not reporting either main outcome. Duplicate reviewers performed study selection, risk of bias assessment, data extraction, and evidence certainty Grading of Recommendations Assessment, Development, and Evaluation appraisal. Main outcomes were postoperative pain by visual analog scale within 72 hours and opioid consumption as morphine milligram equivalent (MME) within 48 hours.
RESULTS
Screening filtered 955 studies to 23 trials containing 1532 patients. Risk of bias was overall low. Scalp block reduced postoperative pain at 2 through 72 hours, visual analog scale mean differences of 0.79 to 1.40. Opioid requirements were reduced at 24 hours by 16.52 MME and 48 hours by 15.63 MME.
CONCLUSION
Scalp block reduces postoperative pain at 2 through 48 hours and may reduce pain at 72 hours. Scalp block likely reduces opioid consumption within 24 hours and may reduce opioid consumption to 48 hours. The clinical utility of these differences should be interpreted within the context of modest absolute reductions, overall care optimization, and patient populations. This is the first level 1A evidence to evaluate scalp block efficacy in craniotomy.
Topics: Humans; Analgesics, Opioid; Nerve Block; Scalp; Randomized Controlled Trials as Topic; Anesthetics, Local; Pain, Postoperative; Craniotomy
PubMed: 36762905
DOI: 10.1227/neu.0000000000002381 -
American Journal of Obstetrics and... Jul 2023This meta-analysis was conducted to (1) assess the quantity and dose of perioperatively dispensed opioids for benign hysterectomy by procedure route and (2) identify the... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
This meta-analysis was conducted to (1) assess the quantity and dose of perioperatively dispensed opioids for benign hysterectomy by procedure route and (2) identify the predictors of persistent opioid use after the procedure.
DATA SOURCES
PubMed, Web of Science, and Embase were systematically searched from study inception to 25 March 2022.
STUDY ELIGIBILITY CRITERIA
Studies reporting data on opioid dispensing among patients undergoing benign hysterectomy were considered eligible. The primary outcome was the dosage of opioids dispensed perioperatively (from 30 preoperative days to 21 postoperative days). The secondary outcome was the predictors of persistent opioid use after benign hysterectomy (from 3 months to 3 years postoperatively). Total opioid dispensing was measured in morphine milligram equivalents units.
METHODS
The random-effects model was used to pool the mean differences or odds ratios and the corresponding 95% confidence intervals.
RESULTS
A total of 8 studies presenting data on 377,569 women undergoing benign hysterectomy were included. Of these women, 83% (95% confidence interval, 81-84) were dispensed opioids during the perioperative period. The average amount of perioperatively dispensed opioids was 143.5 morphine milligram equivalents (95% confidence interval, 40-247). Women undergoing vaginal hysterectomy were dispensed a significantly lower amount of opioids than those undergoing laparoscopic or abdominal hysterectomies. The overall rate of persistent opioid use after benign hysterectomy was 5% (95% confidence interval, 2-8). Younger patient age (odds ratio, 1.38; 95% confidence interval, 1.17-1.63), smoking history (odds ratio, 1.87; 95% confidence interval, 1.67-2.10), alcohol use (odds ratio, 3.16; 95% confidence interval, 2.34-4.27), back pain (odds ratio, 1.50; 95% confidence interval, 1.10-2.05), and fibromyalgia (odds ratio, 1.60; 95% confidence interval, 1.39-1.83) were significantly associated with a higher risk of persistent opioid use after benign hysterectomy. However, there was no significant effect of hysterectomy route and operative complexity on persistent opioid use postoperatively.
CONCLUSION
Perioperative opioid dispensing was significantly dependent on the route of hysterectomy, with the lowest dispensed morphine milligram equivalents of opioids for vaginal hysterectomy and the highest for abdominal hysterectomy. Nevertheless, hysterectomy route did not significantly predict persistent opioid use postoperatively, whereas younger age, smoking, alcohol use, back pain, and fibromyalgia were significantly associated with persistent opioid use.
Topics: Humans; Female; Analgesics, Opioid; Fibromyalgia; Pain, Postoperative; Hysterectomy; Opioid-Related Disorders; Morphine Derivatives
PubMed: 36539027
DOI: 10.1016/j.ajog.2022.12.015 -
CVIR Endovascular Jan 2021A systematic review to determine the effectiveness of intra-arterial anaesthetics on post- operative pain and opioid analgesia requirements in arterial embolisation... (Review)
Review
PURPOSE
A systematic review to determine the effectiveness of intra-arterial anaesthetics on post- operative pain and opioid analgesia requirements in arterial embolisation procedures.
MATERIALS AND METHODS
A systematic review of the literature was performed (Embase, PubMed, MEDLINE and the Cochrane Library) from inception to 10th August 2020. Randomised controlled trials (RCTs) and cohort studies that utilised intra-arterial anaesthesia during an embolisation procedure for the purposes of pain control were included. Eligibility was assessed by two investigators independently.
RESULTS
Eight hundred fifty-nine candidate articles were identified, and 9 studies met the inclusion criteria (6 RCTs and 3 retrospective cohort studies). Four studies were of hepatic chemoembolisation and 5 were of uterine artery embolisation. Five hundred twenty-nine patients were treated in total. All studies used lidocaine as the anaesthetic with doses ranging from 20 to 200 mg, and the anaesthetic was delivered varyingly before, during or after embolisation. Pain intensity was converted to a numeric scale from 0 to 10, and opioid doses were converted to milligram morphine equivalent doses. A random-effects meta-analysis model was used to analyse the results of RCTs, and the results of cohort studies were summarised with a narrative synthesis. The meta-analyses suggested that pain scores were reduced by a mean of 1.02 (95% CI - 2.34 to 0.30; p = 0.13) and opioid doses were reduced by a mean of 7.35 mg (95% CI, - 14.77, 0.06; p = 0.05) in the intervention group however neither finding was statistically significant. No serious adverse events were reported.
CONCLUSION
Intra-arterial anaesthetic may slightly reduce pain intensity and post-operative opioid consumption following embolisation, however the results are not statistically significant. There is very limited data available on the effect of anaesthetic on length of hospital admission. Whilst no serious adverse events were reported, there are some concerns regarding the effect of lidocaine on the technical success of embolisation procedures that preclude our recommendation for routine use in embolisation procedures. High quality randomised controlled trials are required to elucidate the dose-response effect of lidocaine on opioid consumption and pain following embolisation, particularly in the first few hours post-operatively, as well as effects on duration of hospital stay.
PubMed: 33399961
DOI: 10.1186/s42155-020-00198-z -
The Medical Journal of Australia Apr 2022To evaluate the efficacy and safety of opioids for analgesic therapy for people with osteoarthritis. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To evaluate the efficacy and safety of opioids for analgesic therapy for people with osteoarthritis.
STUDY DESIGN
Systematic review and meta-analysis of randomised, placebo-controlled trials of opioid therapies for treating the pain of osteoarthritis. The primary outcome was medium term pain relief (six weeks to less than 12 months). Quality of evidence was assessed with GRADE criteria.
DATA SOURCES
MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews and Central Register of Controlled Trials, CINAHL, PsycINFO, AMED, and the WHO International Clinical Trials Registry; trials published to 31 October 2020.
DATA SYNTHESIS
We extracted pain, disability, health-related quality of life, and adverse events data for 36 eligible trials (overall dose range: 10-210 oral morphine milligram equivalents [MME] per day). Continuous pain and disability outcomes were converted to common 0-100-point scales; changes of less than ten points were deemed to be very small effects. Differences in dichotomous outcomes were expressed as risk ratios. Data were pooled for meta-analysis in random effects models. The evidence from 19 trials (8965 participants; dose range, 10-126 MME/day) for very small medium term pain relief (mean difference [MD], -4.59 points; 95% CI, -7.17 to -2.02 points) was low quality, as was that from 16 trials (6882 participants; dose range, 10-126 MME/day) for a very small effect on disability (MD, -4.15 points; 95% CI, -6.94 to -1.35 points). Opioid dose was not statistically significantly associated with either degree of pain relief or incidence of adverse events in a meta-regression analysis. Evidence that opioid therapy increased the risk of adverse events (risk ratio, 1.43; 95% CI, 1.29-1.59) was of very low quality.
CONCLUSIONS
Opioid medications may provide very small pain and disability benefits for people with osteoarthritis, but may also increase the risk of adverse events.
PROSPERO REGISTRATION
CRD42019142813 (prospective).
Topics: Analgesics, Opioid; Humans; Osteoarthritis; Pain Management; Prospective Studies; Quality of Life
PubMed: 35137418
DOI: 10.5694/mja2.51392 -
Surgical Endoscopy Jan 2023A paucity of literature exists regarding current opioid prescribing and use following bariatric surgery. We aimed to characterize opioid prescribing practices and use... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
A paucity of literature exists regarding current opioid prescribing and use following bariatric surgery. We aimed to characterize opioid prescribing practices and use following bariatric surgery to inform future studies and optimized prescribing practices.
METHODS AND PROCEDURE
We performed a systematic review of Ovid MEDLINE, Ovid Embase, Scopus, Web of Science Core Collection, and Cochrane Library (via WILEY) on August 20, 2021. Two reviewers reviewed and extracted data independently. Studies evaluating adult patients undergoing bariatric surgery that reported opioid prescriptions at discharge were included. Abstracts, non-English studies, and those with n < 5 were excluded. Primary outcomes assessed the amount of morphine milligram equivalents (MMEs) prescribed at discharge. Secondary outcomes evaluated opioids used following discharge, proportion of patients with unused opioid, and if unused opioids were properly discarded.
RESULTS
We evaluated 2113 studies, with 18 undergoing full-text review, and 5 meeting inclusion criteria. Overall, 847 patients were included, with 450 (53%) undergoing sleeve gastrectomy and 393 (46%) receiving Roux-en-Y gastric bypass. Most patients were female (n = 484/589, 82.2%), and the average age and BMI were 44.6 (± 11.8) years and 48.1 kg/m (± 8.4 kg/m), respectively. On average, 348.4 MMEs were prescribed to patients undergoing bariatric surgery. Patients used only 84.7 MMEs, with 87.0% (95% CI 66.0-99.0%) having unused opioid, and 41/120 (34.2%) retaining these excess opioids.
CONCLUSION
Nearly 90% of all bariatric patients evaluated in our systematic review are prescribed excessive opioids at discharge. Further work characterizing current opioid prescribing practices and use may help guide development of standardized post-bariatric surgery prescription guidelines.
Topics: Adult; Female; Humans; Male; Analgesics, Opioid; Bariatric Surgery; Gastric Bypass; Pain, Postoperative; Practice Patterns, Physicians'; Retrospective Studies; Middle Aged
PubMed: 35927352
DOI: 10.1007/s00464-022-09481-7 -
Psychiatry and Clinical Neurosciences Sep 2022Brexpiprazole augmentation is an effective treatment strategy for antidepressant-refractory depression, but its optimal dosage remains unclear. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Brexpiprazole augmentation is an effective treatment strategy for antidepressant-refractory depression, but its optimal dosage remains unclear.
AIMS
To find the optimal dosage of brexpiprazole as augmentation of other antidepressants.
METHODS
We searched multiple electronic databases (from inception to September 16th, 2021) to identify double-blind, randomized placebo-controlled fixed-dose trials evaluating brexpiprazole augmentation therapy in adults (≥18 years old, both genders) with major depressive disorder not adequately responding to one or more antidepressant treatment. Our outcomes of interest at 8 weeks (range 4-12 weeks) were efficacy (treatment response defined as 50% or greater reduction in depression severity), tolerability (dropouts due to adverse effects) and acceptability (dropouts for any reason). We performed a random-effects, one-stage dose-effect meta-analysis with restricted cubic splines.
RESULTS
Six studies met the inclusion criteria, including 1671 participants in total. The dose-efficacy curve showed an increase up to doses around 2 mg (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.12-2.06) and then a decreasing trend through the higher licensed dose up to 3 mg (OR 1.40, 95% CI 0.95-2.08). The shape of the dose-tolerability curve was comparable to that of the efficacy and the dose-acceptability curve showed a monotonic increasing trend but both had wide confidence bands.
CONCLUSIONS
One to two milligrams of brexpiprazole as augmentation treatment may achieve an optimal balance between efficacy, tolerability, and acceptability in the acute treatment of antidepressant-refractory depression. However, the small number of included studies limit the reliability of the results. Further research is required to validate the findings.
Topics: Adolescent; Adult; Antidepressive Agents; Depressive Disorder, Major; Depressive Disorder, Treatment-Resistant; Female; Humans; Male; Quinolones; Randomized Controlled Trials as Topic; Reproducibility of Results; Thiophenes
PubMed: 35716011
DOI: 10.1111/pcn.13438 -
International Journal of Clinical... Apr 2021Background Duloxetine is currently approved for chronic pain management; however, despite some evidence, its utility in acute, postoperative pain remains unclear Aim of... (Meta-Analysis)
Meta-Analysis Review
Background Duloxetine is currently approved for chronic pain management; however, despite some evidence, its utility in acute, postoperative pain remains unclear Aim of the review This systematic review and meta-analysis is to determine if duloxetine 60 mg given perioperatively, is safe and effective at reducing postoperative opioid consumption and reported pain following elective orthopedic surgery. Method CINAHL, Medline, Cochrane Central Registry for Clinical Trials, Google Scholar, and Clinicaltrials.gov were searched using a predetermined search strategy from inception to January 15, 2019. Covidence.org was used to screen, select, and extract data by two independent reviewers. Individual study bias was assessed using the Cochrane Risk of Bias tool. Opioid consumption data were converted to oral morphine milligram equivalents (MME) and exported to RevMan where meta-analysis was conducted using a DerSimonian and Laird random effects model. Results Six randomized-controlled trials were included in the literature review of postoperative pain and adverse effects. Five studies were utilized for the meta-analysis of postoperative opioid consumption; totaling 314 patients. Postoperative pain analysis showed variable statistical significance with overall lower pain scores with duloxetine. Adverse effects included an increase in insomnia with duloxetine but lower rates of nausea and vomiting. Meta-analysis revealed statistically significant [mean difference (95% CI)] lower total opioid use with duloxetine postoperatively at 24 h [- 31.9 MME (- 54.22 to - 9.6), p = 0.005], 48 h [- 30.90 MME (- 59.66 to - 2.15), p = 0.04] and overall [- 31.68 MME (- 46.62 to - 16.74), p < 0.0001]. Conclusion These results suggest that adding perioperative administration duloxetine 60 mg to a multimodal analgesia regimen within the orthopedic surgery setting significantly lowers total postoperative opioid consumption and reduces pain without significant adverse effects.
Topics: Analgesia; Analgesics, Opioid; Duloxetine Hydrochloride; Humans; Orthopedic Procedures; Pain, Postoperative
PubMed: 33459948
DOI: 10.1007/s11096-020-01216-9 -
The Western Journal of Emergency... May 2023Ketamine can be particularly helpful in situations where the clinician is not able to administer opioids and require an alternate analgesic, such as for patients who are... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Ketamine can be particularly helpful in situations where the clinician is not able to administer opioids and require an alternate analgesic, such as for patients who are already on high-dose opioids, have a history of addiction, or for opioid-naïve children and adults. In this review, our goal was to obtain a comprehensive estimate of the efficacy and safety of low-dose ketamine (dose less than 0.5 milligrams per kilogram or equivalent) compared to opiates for the control of acute pain in the emergency setting.
METHODS
We conducted systematic searches in PubMed Central, EMBASE, MEDLINE, the Cochrane Library, ScienceDirect, and Google Scholar from inception until November 2021. We used the Cochrane risk-of-bias tool to assess the quality of included studies.
RESULTS
We carried out a meta-analysis with a random-effects model and reported pooled standardized mean difference (SMD) and risk ratio (RR) with 95% confidence intervals depending on the type of the outcome. We analyzed a total of 15 studies with 1,613 participants. Half of them had high risk of bias and were conducted in the United States of America. The pooled SMD for pain score was -0.12 (95% CI -0.50-0.25; I2=68.8%) within 15 minutes, -0.45 (95% CI -0.84--0.07; I2=83.3%) within 30 minutes, -0.05 (95% CI -0.41-0.31; I2=86.9%) within 45 minutes, -0.07 (95% CI -0.41-0.26; I2=82%) within 60 minutes, and after 60 minutes the pooled SMD was 0.17 (95% CI -0.07-0.42; I2=64.8%). The pooled RR for need of rescue analgesics was 1.35 (95% CI 0.73-2.50; I2=82.2%). The pooled RRs were as follows: 1.18 (95% CI 0.76-1.84; I2=28.3%) for gastrointestinal side effects; 1.41 (95% CI 0.96-2.06; I2=29.7%) for neurological side effects; 2.83 (95% CI 0.98-8.18; I2=47%) for psychological side effects; and 0.58 (95% CI 0.23-1.48; I2=36.1%) for cardiopulmonary side effects.
CONCLUSION
Low-dose ketamine might have higher or equivalent efficacy and safety when compared to opioids for managing acute pain among patients presenting to the emergency setting. However, further studies are required to establish conclusive evidence, owing to the heterogeneity and poor quality of existing studies.
Topics: Adult; Child; Humans; Analgesics, Opioid; Ketamine; Acute Pain; Randomized Controlled Trials as Topic; Analgesics
PubMed: 37278798
DOI: 10.5811/westjem.2023.2.58368